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Colombian Journal of Anestesiology

versión impresa ISSN 0120-3347

Rev. colomb. anestesiol. vol.40 no.2 Bogotá abr./jun. 2012

https://doi.org/10.1016/S0120-3347(12)70025-4 

http://dx.doi.org/10.1016/S0120-3347(12)70025-4

Essay

 

Training of General Practitioners in Accordance With the Requirements of the Colombian Social Security System

La formación de médicos generales según los requerimientos del sistema general de seguridad social en salud en Colombia

 

Juan M. Ospinaa ,Fred G. Manrique-Abrilab*, Abel Fernando Martinez-Martina

a Escuela de Medicina, Universidad Pedagógica y Tecnológica de Colombia, Tunja, Colombia
b Facultad de Enfermería, Universidad Nacional de Colombia, Bogotá, Colombia

Corresponding author: Universidad Pedagógica y Tecnológica de Colombia, Avda. Central del Norte, Tunja, Boyacá, Colombia. E-mail: fgmanriquea@unal.edu.co (F.G. Manrique); juan.ospina@uptc.edu.co (J.M. Ospina).

ARTICLE INFO

Article history: Received: July 29, 2011 Accepted: February 15, 2012

ABSTRACT

The following is a historical perspective of the most relevant concepts and events that resulted in the development and structuring of the model for the Social Security System in Healthcare, and of the curricular models for medical training in Colombia. This review highlights the controversial issues and the aspects that warrant agreements that would lead to improvements for the benefit of the two areas, namely, training of general practitioners and the quality of healthcare provision.

Keywords: Medical Education Health Physicians Health Systems

© 2011 Sociedad Colombiana de Anestesiología y Reanimación. Published by Elsevier.
All rights reserved.


RESUMEN

Con un enfoque de análisis histórico se hace una reflexion sobre los conceptos y hechos más relevantes que han llevado al desarrollo y estructuración del modelo de Sistema General de Seguridad Social en Salud (SGSSS) y de los modelos curriculares de formación médica en Colombia, para establecer los puntos que constituyen controversia y los aspectos que ameritan un acuerdo de voluntades que podrían llevar a mejorar en beneficio de los dos sectores tanto la formación de médicos generales como la calidad del sistema de prestación de servicios de Salud.

Palabras clave: Educación Médica Salud Médicos Sistemas de Salud

© 2011 Sociedad Colombiana de Anestesiología y Reanimación. Publicado por Elsevier.
Todos los derechos reservados.


Coordination among healthcare training institutions, regulatory agencies and health providers of the Health System created under Law 100 of 1993 is subject to varying perspectives that worsen the current, crisis considering that they compromise timely and effective service provision.

The goal is to examine the origins of the medical training system in order to identify common areas that may be used as a basis for guiding education approaches designed to structure a professional profile suitable for the new technological and organizational realities in healthcare.

Between 1975 and 1993, the Colombian Health System was supported on three pillars: social security, public sector, and private organizations.1 Funding sources were several or mixed. For 15 years, there was no decentralization, although important steps were taken in regionalization, levels of care, policy consolidations, and preventive models in accordance with international guidelines.

In the 1990's a diagnosis revealed failures in the system. Only 31% of the population had access to healthcare services; provincial entities were assigned complex roles such as customer service, environment, health education, community participation and continuing education, creating inefficiencies in the system. The quality of healthcare was poor, and the mechanisms for expense allocations were amenable to corruption; budgets were prepared on the basis of historical data, and the system showed inequality and absence of solidarity.2

The underpinnings for the health reform were articles 48 and 49 of the Political Constitution, which shifted the concept of health from a concept of fundamental right to that of public service.

Law 100/93 implemented a social security model3 based on the principles of universality, solidarity and efficiency, free market, competition and user discretionary ability to select the service provider, regulation mechanisms, financial solidarity between the contributive and the subsidized regimes, and specific planning and coordination roles for the government sector.4

As a production chain, the system is able to identify the primary stakeholders: customers, suppliers, managing organizations (EPS) and healthcare providers (IPS). It operates as a regulated market system under the oversight and control of the Ministry of Health, the Regulatory Commission (CRES) and the Health Superintendency. Transactional costs are high due to the uncertainty of the demand and the complex nature of the inputs to be negotiated; transactions have oligopolistic, and even monopolistic, characteristics.5 There is a marked imbalance, in terms of numbers and costs, between the contributive and the subsidized regimes.

There was ambiguity in the establishment of primary healthcare, with a focus on education and specific programs around prenatal care, vaccination, and growth and development as the main pillars. This was a setback in relation to achievements of the previous system, evidenced by the reemergence of vector-transmitted diseases, perinatal/ child mortality, and low vaccination coverage.6

In 2010, coinciding with the world economic recession, the crisis became evident as a result of structural and operational failings. The deficit, amounting to an estimated 900 billion pesos, evidenced the regulatory chaos, considering that the largest health management organizations (EPS) had reported profits.7

The reform considered changes in service provision, although it did little or nothing regarding the desirable competencies of the healthcare workers.8

Little attention has been paid to quality and timeliness in the impact analyses.9 Services are deficient at all levels within the system, but more so in basic care, where concepts such as "the deadly journey" or the need to resort to action for civil protection are rampant and undermine the prestige and credibility of the system,10 to the extent that managers and

providers pay too much attention to financial results, at the expense of social benefits.11

Medical Education: From the Comprehensive Past to the Specific Present

In the mid 1970's, medical education followed the Flexnerian model: minimum requirements for admission, minimum duration of the program, basic and clinical divisions, tenured professors, teaching hospitals that depended administratively from their Universities, faculty excellence, and research.12

Training was focused on pathophysiological analysis and aimed for skills requiring knowledge of structural damage and dysfunction. Until the passing of Law 100/93, general practitioners had to make therapeutic decisions in the ambulatory and hospital settings. Risk-focused prevention was approached superficially.

With technological advances came the optimistic approach to chronic diseases such as cancer, degenerative diseases, transplants, and viral infections that had been considered unsolvable in the past. These led to a priority interest in specialization,13,14 since the job of the general practitioner is limited to routine control and referral activities.15

The System has had a deleterious impact on one of the pillars of medical training: the university hospitals, many of which have closed for "restructuring".7 Service providers (IPS) do not consider teaching-service agreements profitable, and there are limited possibilities of training in clinical competencies such as semiology. Students face restrictions in their approach to patients, which undermines the possibility of training professionals capable of winning the trust of their patients and of interpreting disease processes.

Technological breakthroughs in the field of diagnosis, available only in Level III hospitals, lead students, in the absence of training in semiology, to learn how to interpret results. Consequently, when faced with the clinical practice in a Level I healthcare institution, without advanced technology to work with, they fall into a crisis of performance that translates into error and higher costs (because their option is to make referrals).

Graduate programs in Colombia date back to 1962: the Colombian Association of Medical Schools (ASCOFAME) created the General Council of Medical Specialties and established minimum requirements and the duration and structure of the programs.16 In 2002, it proposed a flexible and adaptable undergraduate curriculum designed to train professionals that fit the requirements of the EPS and IPS organizations.

The medical training goals and the financial goals of the Social Security System have a perfect fit, where general practitioners will be excellent at making diagnosis and management decisions of the most endemic diseases.17

The practice environment limits the physician's own independence and initiative since it imposes regulations framed within a financial perspective: it pays no heed to the complex circumstance of the formal medical practice and the role that time plays in terms of prognosis and timeliness for solving simple problems that may become complicated within a short period of time. This functional structure, far from

New Approaches to Medical Training

Change calls for new thinking about adequate strategies to maintain a medical training methodology aimed at developing in the students the competencies suited to the epidemiological profile.

Priority must be given to pathophysiological and risk approaches in order to determine the characteristics of the patient's environment that impact prognosis. Preventive medicine must be the underpinning for primary health care.

One new paradigm and two training methodologies have emerged: problem-based learning (PBL) and simulation techniques framed within the concept of evidence-based medicine (EBM).

EBM and epidemiology explore various areas such as etiology, prognosis, therapeutic guidelines, prevention, efficacy and effectiveness, impact and quality of technology, thus creating a sound body of knowledge in health. EBM is a learning process that integrates clinical experience and evidence: how to find the best information and analyze it for validity and usefulness. It integrates clinical experience with the best levels of evidence for the benefit of the patient.19

PBL, as a teaching approach, facilitates teaching and learning, emphasizes self-learning and self-training. It is a dynamic constructivist approach that promotes cognitive autonomy. Instructors teach and students learn as they work on meaningful problems, error is used as an opportunity, and self-assessment and individualized qualitative learning evaluation are valued.20

Simulation provides expertise, mental fluency and timely response; in critical situations, these are necessary, inescapable and undeferrable skills. The experiences with simulation started in aviation, to help pilots respond quickly and correctly in short periods of time, in simulated flying conditions.21 However, no simulation model can replace the live experience of dealing with human beings in the role of patients.

In an attempt at building training scenarios, simulated medical situations have been explored using actors. Although it has not been evaluated, this could be an option.

The drive to do research is a competency that has received only partial attention in training. Epidemiological research, together with PBL methodologies, could potentiate the ability to create knowledge, and could represent a unique educational strategy in the future.

Funding

Authors' own resources.

Conflict of interests

None declared.

REFERENCES

1. Gaviria A, Medina C, Mejía C. Evaluation the Impact on Health Care Reform in Colombia, From Theory to Practice. Bogotá: CEDE, Uniandes; 2006.

2. Santamaría M, García F, Prada CF, Uribe MJ, Vásquez T. El sector salud en Colombia: impacto del SGSSS después de más de una década de reforma. Bogotá: Fedesarrollo; 2008.

3. Frenk J, Londoño JL. Pluralismo estructurado: hacia un modelo innovador para la reforma de los sistemas de salud. Boletín Salud y Gerencia. 1997;15:6-28.

4. Hernández M. Reforma sanitaria, equidad y derecho a la salud en Colombia. Cad Saúde Pública. 2002;18:991-1001.

5. Gorbaneff Y, Torres S, Contreras N. Anatomía de la cadena de prestación de salud en Colombia en el régimen contributivo. Innovar. 2004;14:168-81.

6. Patiño Restrepo JF. El Proyecto de Ley 052. Rev Colomb Cir. 2005;20:176-8.

7. Nieto J, Borrero F. Evolución de la educación médica en Colombia. Rev Colomb Cir. 2005;20:179-91.

8. Delgado-Ramírez M. ¿Será posible la formación ética y profesional de médicos y especialistas en el sistema de salud actual? Rev Colomb Anestesiol. 2011;39:15-9.

9. Uribe J. Perspectivas del Sector Salud y de la Práctica Médica en el país. Revista Colombiana de urología. 1999;VIII cited Aug 24, 2010. Available from: http://www.encolombia.com/medicina/urologia/urologia8399-laperspectiva.htm

10. Midgley J. ¿La Seguridad Social ha perdido relevancia? Rev Int Seg Soc. 1999;55:111-21.

11. Franco A. Seguridad social y salud en Colombia: estado de la reforma. Rev Salud Pública. 2000;2:1-16.

12. Rosselli DA, Moreno IS. El Desarrollo Histórico de las Especialidades Médicas en Colombia. MedUNAB. 2000;3(8) cited Aug 24, 2010. Available from:http://editorial.unab.edu.co/revistas/medunab/pdfs/r38hm_c1.html

13. Rivero Serrano O. Factores que han modificado la prácticamédica. Rev Fac Med UNAM. 2002;45:258-60.

14. Terrés Speziale AM. Medicina del tercer milenio. Rev Med IMSS. 1998;36:245-52.

15. Wilson CB. The impact of medical technologies on the future of hospitals. BMJ. 1999;319:1287-94.

16. ASCOFAME. Las especialidades medicoquirúrgicas. Informe consolidado 2002-2003. Bogotá: ASCOFAME; 2004 updated 2004; cited Aug 24, 2010. Available from: http://ascofame.org.co/boletin/ev/fn/informeconsolidado.20022003.especialidades.doc

17. Cañones Garzon PJ. El perfil profesional del médico general. El médico-Anuario 2001. 2001;1:32-4. Available from: http://www.medynet.com/elmedico/documentos/anuarioap2001/32-34.pdf

18. Patiño Restrepo JF. Paradigmas y dilemas de la medicina moderna en el contexto de la atención gerenciada de la salud: un dilema ético y un imperativo social. Medicina. 2001;23:169-78.

19. Sackett DL, Rosenberg W, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ. 1996;312:71-2.

20. Dueñas VH. El aprendizaje basado en problemas como enfoque pedagógico en la educación en salud. Colomb Med. 2001;32:189-96.

21. Gough VE, Whitehall SG. Universal tyre test machine. F.I.S.I.T.A.; 1962.

1. Gaviria A, Medina C, Mejía C. Evaluation the Impact on Health Care Reform in Colombia, From Theory to Practice. Bogotá: CEDE, Uniandes; 2006.         [ Links ]

2. Santamaría M, García F, Prada CF, Uribe MJ, Vásquez T. El sector salud en Colombia: impacto del SGSSS después de más de una década de reforma. Bogotá: Fedesarrollo; 2008.         [ Links ]

3. Frenk J, Londoño JL. Pluralismo estructurado: hacia un modelo innovador para la reforma de los sistemas de salud. Boletín Salud y Gerencia. 1997;15:6-28.         [ Links ]

4. Hernández M. Reforma sanitaria, equidad y derecho a la salud en Colombia. Cad Saúde Pública. 2002;18:991-1001.         [ Links ]

5. Gorbaneff Y, Torres S, Contreras N. Anatomía de la cadena de prestación de salud en Colombia en el régimen contributivo. Innovar. 2004;14:168-81.         [ Links ]

6. Patiño Restrepo JF. El Proyecto de Ley 052. Rev Colomb Cir. 2005;20:176-8.         [ Links ]

7. Nieto J, Borrero F. Evolución de la educación médica en Colombia. Rev Colomb Cir. 2005;20:179-91.         [ Links ]

8. Delgado-Ramírez M. ¿Será posible la formación ética y profesional de médicos y especialistas en el sistema de salud actual? Rev colomb anestesiol. 2011;39:15-9.         [ Links ]

9. Uribe J. Perspectivas del Sector Salud y de la Práctica Médica en el país. Revista Colombiana de urología. 1999;VIII. Disponible en: http://www.encolombia.com/medicina/urologia/urologia8399-laperspectiva.htm citado 24 Ago 2010.         [ Links ]

10. Midgley J. ¿La Seguridad Social ha perdido relevancia? Revista internacional de Seguridad Social. 1999;55:111-21.         [ Links ]

11. Franco A. Seguridad social y salud en Colombia: estado de la reforma. Rev Salud Pública. 2000;2:1-16.         [ Links ]

12. Rosselli DA, Moreno IS. El Desarrollo Histórico de las Especialidades Médicas en Colombia. MedUNAB. 2000;3(8). citado 24 Ago 2010. Disponible en: http://editorial.unab.edu.co/revistas/medunab/pdfs/r38hm_c1.html citado 24 Ago 2010.         [ Links ]

13. Rivero Serrano O. Factores que han modificado la práctica médica. Rev Fac Med UNAM. 2002;45:258-60.         [ Links ]

14. Terrés Speziale AM. Medicina del tercer milenio. Rev Med IMSS. 1998;36:245-52.         [ Links ]

15. Wilson CB. The impact of medical technologies on the future of hospitals. BMJ. 1999;319:1287-94.         [ Links ]

16. ASCOFAME. Las especialidades medicoquirúrgicas. Informe consolidado 2002-2003. Bogotá: ASCOFAME; 2004. Disponible en: http://ascofame.org.co/boletin/ev/fn/informeconsolidado.20022003.especialidades.doc actualizado 2004; citado 24 Ago 2010.         [ Links ]

17. Cañones Garzon PJ. El perfil profesional del médico general. El médico-Anuario 2001. 2001;1:32-4. Disponible en: http://www.medynet.com/elmedico/documentos/anuarioap2001/32-34.pdf        [ Links ]

18. Patiño Restrepo JF. Paradigmas y dilemas de la medicina moderna en el contexto de la atención gerenciada de la salud: un dilema ético y un imperativo social. Medicina. 2001;23:169-78.         [ Links ]

19. Sackett DL, Rosenberg W, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ. 1996;312:71-2.         [ Links ]

20. Dueñas VH. El aprendizaje basado en problemas como enfoque pedagógico en la educación en salud. Colomb Med. 2001;32:189-96.         [ Links ]

21. Gough VE, Whitehall SG. Universal tyre test machine. F.I.S.I.T.A. 1962.         [ Links ]